Detecting and Addressing Trauma-related Sequelae in Primary Care.

Objective: The associations between the sequelae of complex trauma symptoms and adult health status, patient engagement in treatment, and the potential impacts on primary care providers are underappreciated despite the potential for adverse outcomes. This study examined the correlations among adult primary care patients' reports of posttraumatic stress symptoms (PTSS), adverse childhood experiences (ACE), and the impacts of social determinants of health (SDH) with provider diagnoses in the electronic health record.Methods: Patients in 3 primary care clinics were surveyed. Self-report measures included demographics, trauma symptoms, ACE, and SDH elements. Participant health status and diagnoses were obtained from their electronic health records.Results: The final sample of 354 participants reported high levels of trauma including PTSS and ACE. Educational attainment, health literacy, material hardship, access to health care, and ACE were all statistically associated with reports of PTSS (P < .05 for all). Despite the prevalence of symptoms and adverse experiences reported by the participants, only 5% were diagnosed with a trauma-related disorder in the electronic health record.Conclusions: Data analyses revealed a significant discrepancy between participants' reports of symptoms with a diagnosis of posttraumatic stress disorder by their primary care doctor. Trauma-impacted patients often present with complicated health problems that may influence the encounter in negative ways, including diminishing the primary care doctor's sense of efficacy and competency if they are not addressed effectively in the encounter. The common nature of ACE, PTSS, and SDH effects indicate that both patients and physicians would benefit from detection and training in strategies for routinely implementing trauma-informed practices.

An evaluation of a simulation and video-based training program to address adverse childhood experiences.

Adverse Childhood Experiences (ACEs) are multiple sources of maltreatment and household dysfunction with tremendous impact on health. A trauma-informed (TI) approach is preferred when working with patients with ACEs. The Professional ACEs-Informed Training for Health© (PATH©) educational program and simulation experience using standardized patients (SP) was developed to help healthcare professionals address ACEs with adults. PATH© is a 3-4 hour curriculum comprised of lecture and discussion, video-based demonstration, simulation experience, and debriefing. It was first developed for primary care (PC) residents in family medicine and internal medicine, and subsequently modified for occupational therapy (OT) and physical therapy (PT) students. This study evaluates a preliminary dataset focusing on PATH© skills of PC residents and OT and PT students during simulation. Recordings of 53 learner-SP encounters from 15 OT and PT students and 38 PC residents were coded using standardized behavioral codes. A subset of ten recordings of PC residents who participated in simulations in the first and fourth year of the training program allowed for evaluation of training outcomes over time. Results showed that medical residents and OT and PT students demonstrated skills during SP encounters congruent with TI training on addressing ACEs with adults, particularly in explaining ACEs, demonstrating empathy, collaborative treatment planning, and stigma reduction. PC residents showed both positive and negative changes in PATH©-specific skills from year 1 to 4 of the training program. This study supports the PATH© model and simulation-based training in preparing clinicians to address ACEs with adults and provides insight into further curriculum improvement.

A simulation and video-based training program to address adverse childhood experiences.

Adverse childhood experiences (ACEs) are 10 categories of childhood abuse and maltreatment, which have a dose-response relationship with common adult health concerns seen in primary care including health risk behaviors, chronic disease, and mental illness. Many of the ACEs-associated biopsychosocial risk factors are modifiable. However, physicians may not address these issues for fear of opening "Pandora's Box", that is, a source of extensive problems for which they are not sufficiently prepared with training, resources, or time. Residents need training in how to conduct trauma-focused conversations within the limited scope of an office visit. To address this need, a 4-hour simulation and video-based training program was developed for primary care residents about how to conduct brief interventions connecting their patients' current health concerns with their experiences of ACEs. Resident participants have evaluated this program as preparatory for real-life encounters and as being designed to allow for educational mastery. This article describes a workshop presenting this training program which was given at the 37th Annual Behavioral Science Forum in Family Medicine. Five skills targeted in the program were presented and a demonstration was made of the components, that is, didactics, provider and patient videos, simulated patient encounters, trainee feedback, and facilitated discussion that encompasses targeted skills, clinical implementation, and self-care. Companion tools were shared, including the syllabus, evaluation rubric, and provider and patient resources. Participants practiced trainee feedback and discussed the challenges in implementation.

A pilot study of psychiatry resident psychotherapy competency: the impact of resident attitude and demographics.

OBJECTIVE: In psychiatry education, psychotherapy knowledge, skills, and attitudes are new competency objectives. METHODS: Two faculty members independently ranked psychiatry residents for psychotherapy competency. A rank of 1 indicated the most competency and a rank of 15 indicated the least competency for the resident psychotherapist. Several demographic and attitudinal variables of the residents were examined for relationships with psychotherapy competence. RESULTS: When the competency rankings of the two faculty members were compared, they demonstrated a high level of agreement (spearman r = 0.74, p = 0.0016). Of the variables studied, resident age (r = .61, p = .015) and personal attitude toward psychotherapy (S=29, p = .026) were significantly associated with psychotherapy competency. Both variables remained independently significant after statistical adjustment. CONCLUSIONS: Our study indicates that psychiatry resident attitude and age may influence psychotherapy competency. These markers for psychotherapy competency may assist training programs with resident selection parameters and may enhance psychotherapy educational strategies for residents predicted to require assistance in achieving competency.

Validity of the distinction between primary and secondary substance use disorder in patients with bipolar disorder: data from the first 1000 STEP-BD participants.

The validity of a primary/secondary substance use disorder (SUD) distinction was evaluated in the first 1000 patients enrolled in the Systematic Treatment Enhancement Program for Bipolar Disorder. Patients with primary SUD (n = 116) were compared with those with secondary SUD (n = 275) on clinical course variables. Patients with secondary SUD had fewer days of euthymia, more episodes of mania and depression, and a greater history of suicide attempts. These findings were fully explained by variations in age of onset of bipolar disorder. The order of onset of SUDs was not linked to bipolar outcomes when age of onset of bipolar disorder was statistically controlled. The primary/secondary distinction for SUD is not valid when variations in the age of onset of the non-SUD are linked to course characteristics.

A pilot use of team-based learning in psychiatry resident psychodynamic psychotherapy education.

OBJECTIVE: Demonstrating psychotherapy competency in trainees will test the resources of psychiatry training programs. The authors outline the phases of team-based learning (TBL). METHODS: The University of Oklahoma College of Medicine, Tulsa (OUCM-T), Department of Psychiatry reorganized its psychodynamic psychotherapy didactic course using TBL. CONCLUSION: Team-based learning offers a promising alternative to traditional psychodynamic psychotherapy didactics, potentially increasing resident learning efficiency through a structured learning cycle emphasizing accountability to a learning team.

Primary care specialty, resident status, and male gender correlate with controlled drug contract use.

OBJECTIVE: With prescription drug abuse rising, physicians are often ambivalent about prescribing controlled drugs. To address their concerns, physicians widely use controlled drug contracts (CDC); however, CDC use is poorly studied. This preliminary study characterizes CDC users and identifies factors associated with CDC use. METHOD: Data were collected from a Web-based survey of University of Oklahoma College of Medicine medical trainee and faculty attitudes and prescribing practices regarding controlled drugs. Recruited via e-mail, participants submitted responses anonymously for a 6-week period from January through March 2004. Associations between demographic variables and participants' responses were analyzed using chi2 analysis to determine correlates of CDC use. Demographic variables included training status (medical student, resident, or faculty), age, gender, and faculty specialty. Variables of interest derived from the survey were CDC use, how respondents compared the risks and benefits of controlled drugs, and patient diagnosis. RESULTS: One hundred ninety-six surveys were submitted, with an estimated response rate of 20% to 30%. CDC use correlated with male gender (p = .0099), resident status (p = .0099), primary care specialty among faculty (p = .0001), and risk/benefit assessment (p = .04) but not patient diagnosis (p = .19) or participant age (p = .40). CONCLUSIONS: Despite limitations, the study findings suggest that a physician's gender, training status, medical specialty, and comparison of the risks and benefits of controlled drugs are factors that determine CDC use.